Delivering essential care: A Canadian nurse with MSF in South Sudan

At the heart of Doctors Without Borders/Médecins Sans Frontières (MSF)'s medical humanitarian action is the provision of essential care to people who otherwise have no access to basic health services. Responding to these fundamental needs puts MSF medical teams on the ground in close to 70 countries around the world, where people are affected by conflict, epidemics, disaster or exclusion. In the piece below, Canadian nurse Gloria Yuen describes how she and her local colleagues worked to address the critical health gaps in one of the world's most troubled countries: South Sudan.

Usually when I tell people in Canada that I was recently in South Sudan, they have no idea there is a conflict going on there. Largely ignored by international media, South Sudan often feels like a forgotten country embroiled in a forgotten war. A wave of sectarian violence that began in late 2013 has killed thousands of people and displaced millions, and has created an urgent need for humanitarian aid.

But even before this most recent conflict began, South Sudan already faced significant humanitarian challenges, including a critical lack of essential healthcare in many parts of the country. The current conflict has only made this situation worse, as widespread displacement and instability have increased incidences of malnutrition, infection and disease. I recently spent six months working as a nurse and outreach team supervisor with Doctors Without Borders/Médecins Sans Frontières (MSF) in the town of Bentiu, tucked in to the northern part of South Sudan, and I saw first-hand the urgent health needs in an area where medical services, along with food, shelter and security, are in short supply.

MSF runs two projects in Bentiu: one is a 160-bed secondary healthcare hospital that serves the Protection of Civilians (PoC) site established by the United Nations for more than 115,000 people displaced by the conflict. The second project provides outreach and maternity services to those living in Bentiu outside of the camp. It was here that I worked with a team of locally hired MSF staff, and my time there coincided with peak season for one of South Sudan’s most deadly killers: malaria.

There are essentially two seasons in South Sudan – hot and dry, and not-as-hot and rainy. The torrential downpours are a welcome relief from the stifling heat, but also herald an insect season of biblical proportions. Malaria becomes an enormous burden and is a leading cause of mortality in all age groups. For four months, the MSF medical outreach team in Bentiu tirelessly ran a malaria point in the centre of town to rapidly diagnose and treat uncomplicated cases. At the peak of malaria season, our team saw upwards of 200 people a day. By the time we closed the malaria point at the end of October, the outreach team had screened over 10,000 people, treating nearly 7,500 positive cases in this small town.

Malaria season in South Sudan can seem both merciless and relentless. At some points, our radios squawked incessantly with new alerts of yet more critically ill people arriving at the gate of our clinic. Parents sometimes arrived in tears, cradling convulsing children in their arms, having run for hours from an outlying village with no medical services. Unconscious and feverish adults would be carried in by family members on homemade stretchers made of rope and torn sheets. On some occasions, it was too late. We once had to tell a young mother that her son was, in fact, already dead by the time she arrived at our compound. She told us that he had a high fever for several days and had started to convulse before she wrapped him in a blanket and carried him to us. She slowly wrapped her son’s body back up in the blanket and walked away.

Gloria Yuen and her colleagues on the MSF outreach team bring medical care and consultation to people outside of Bentiu in South Sudan.

Responding to needs

Our health promotion team canvassed the town week after week to remind people to use their mosquito nets and to seek medical help early. Illustrated flipbooks, stories and songs were especially effective for spreading messages. Daily household visits also gave the outreach team a chance to identify and follow up on sick people in the community. Sometimes we would find lethargic children lying on the floor, skin blazing hot, eyes glazed and barely responsive. In a place where conflict and violence remains ongoing, many women have been left on their own to care for their families, and it was not uncommon to find only young children at home looking after their younger siblings while their mother collected firewood or sold tea at the market.

Life seemed especially difficult for some of the women I met. South Sudan has one of the highest maternal and neonatal mortality rates in the world. Many women deliver at home either alone or in the presence of untrained birth attendants. We often saw labouring mothers with complications that could have been easily prevented with basic prenatal care, such as an early diagnosis of malaria or syphilis. Sometimes we were able to stabilize patients before transferring them to the larger hospital in the PoC – other times, we were not so lucky. As one of the South Sudanese midwives gently told me, “God gives us some children, and God takes away some.”

As if that were not challenging enough, women face an enormous risk of rape, which in South Sudan is highly stigmatized and underreported. Through household visits and community meetings, we heard countless reports from women of all ages who had survived horrific sexual assaults. Our female outreach workers were especially passionate about educating the community on the importance of seeking immediate medical care after a sexual assault. The team discretely looked for signs of sexual violence when they spoke with women in the community, and quietly accompanied survivors to our clinic. They stayed beyond their working hours to walk the women home, or to bring survivors to the compound on the weekends and at night. It was heartbreaking work for everyone involved.

Gloria Yuen and her colleagues at MSF's medical project in Bentiu, South Sudan.

MSF's dedicated South Sudanese staff

MSF’s locally hired staff are the beating hearts of our projects around the world. In Bentiu, they seemed to embody the resilience and strength of the South Sudanese, and the outreach team was my lifeline to the local community. Our drivers skillfully navigated muddy fields and flooded roads to deliver emergency supplies or to pick up a critically ill patient. Guards performed double duty as translators at night when patients would show up in medical distress. They all had heartbreaking stories of their own to tell; one of our midwives told me how she had sent her children to live with family in the safety of a refugee camp in Uganda, and she was slowly saving money to travel to see them. It would take at least a week to travel to Uganda by public transport. She hadn’t seen her children in three years.

Some of my colleagues had been in Bentiu since before the most recent conflict began, and they described it as a shell of its former self. As we walked through the town, my colleagues would point out where a vast field of overgrown grass used to be a flourishing market, “before the crisis”; now there was only a pile of bricks here and there, or an ornate metal door standing alone. The town has been without electricity for years because there is no fuel to run the power station. At night Bentiu is eerily quiet, the ambience broken only by the hum of the generator at MSF’s compound, the darkness by our scattered lights.

It was a privilege for me to support MSF’s my South Sudanese colleagues in Bentiu with the incredible work that they do. I may have only spent six months in a small corner of South Sudan, but I came home humbled. Without peace and stability in South Sudan, people continue to suffer from the lack of basic necessities and access to essential health services such as safe birthing options, clean water, primary healthcare and medications, just to name a few. As humanitarians, we must bear witness to the suffering of people living there, tell their stories, and do all we can to help.

Gloria Yuen is a Canadian nurse who lives and works in British Columbia.

In the town of Bentiu, in South Sudan, MSF currently provides reproductive health care, including post-natal care for mother and child, medical care for survivors of sexual violence and treatment of sexually transmitted infection for women and their partners. An outreach team provides health promotion activities with a focus on sensitizing the community on available medical and psychological care for survivors of sexual violence. This year, three emergency malaria points were opened in Bentiu town to respond to the high number of malaria cases. In 2016, MSF expandeds operations in the area to answer the needs of the local communities living in remote places and suffering from a limited access to basic services, including healthcare. As of August 2018, MSF runs mobile basic healthcare clinics in 11 locations in Leer and Mayendit counties, with the aim of reducing key morbidities such as malaria, respiratory tract infections, diarrhea and skin infections, and providing emergency medical care for survivors of sexual violence. From January to June this year, the project ensured 42,853 outpatient consultations, including the treatment for 522 malaria cases.